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Maternal and Neonatal Health Impact of Obstetrical Risk Insurance Scheme

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Maternal and Neonatal Health Impact of Obstetrical Risk Insurance Scheme Health Policy and Planning Advance Access published October 22, 2016 Health Policy and Planning, 2016, 1–13 doi: 10.1093/heapol/czw142 Original Article Maternal and neonatal health impact of obstetrical risk insurance scheme in Mauritania: a quasi experimental before-and-after study Aline Philibert,1,2 Marion Ravit,3 Vale´ry Ridde,4,5 Ine`s Dossa,2 Emmanuel Bonnet,6 Florent Bedecarrats7 and Alexandre Dumont3 1 Interdisciplinary Research Centre on Well-being, Health, Society and Environment (Cinbiose), University of Downloaded from Quebec in Montreal, Montreal, Que´bec, Canada, 2Research Institute for Development, Universite´Paris Descartes, COMUE Sorbonnes Paris Cite´, UMR MERIT, Paris, France, 3IRD, CEPED, UMR 196, Universite´ Paris Descartes— Institut de Recherche pour le De´veloppement (IRD), Paris, France, 4School of Public Health (ESPUM), University of Montreal, Montreal, Quebec, Canada, 5University of Montreal Public Health Research Institute (IRSPUM), 6 Montreal, Quebec, Canada, UMR IDEES CNRS 6266, Universite´de Normandie/IRD RESILIENCE 236, Caen, France, http://heapol.oxfordjournals.org/ 7Agence Franc¸aise de De´veloppement (AFD), Evaluation Unit, Research and Knowledge Developpement, Paris, France Corresponding author. Aline Philibert, CINBIOSE, Universite´ du Que´bec a Montre´al, Case postale 8888, Succursale Centre-ville, Montre´al (Que´bec) H3C 3P8 Canada, e-mail: [email protected] Accepted on 22 September 2016 Abstract A variety of health financing schemes shaped on pre-payment scheme have been implemented at Universite de Montreal on October 24, 2016 across Sub-Saharan Africa (SSA) to address the Millennium Development Goals (MDGs). In Mauritania, the Obstetric Risk Insurance package (ORI) focusing on maternal and perinatal health has been progressively implemented at the health district level since 2002. Here, our main object- ive was to assess the effectiveness of the ORI in increasing facility-based delivery rates, as well as increases in family planning, antenatal and postnatal care, caesarean delivery and neonatal health, from demographic and health survey data between 2002 and 2011. We also examined whether the effects of the ORI varied between strata of the population. The study was based on a quasi- experimental before-and-after design to assess the causal link between availability of ORI and in- crease in use of maternal health services and neonatal mortality. In combination with geographical information system, difference-in-differences and odd ratio approaches were used to address our objectives. Indicators of access to care for pregnant women and neonatal health and improved in both non-intervention and intervention groups during the study period. There was no global effect of the availability of ORI on facility-based delivery rates, nor on the use of antenatal and postnatal care services, except for qualified antenatal services. However, delivery rates in local health centres with ORI increased more rapidly than in those with no ORI, the contrary was shown for hospitals. Caesarean delivery and family planning decreased with ORI. Although late neonatal mortality rates remained low in the country, a significant decrease was seen in districts without ORI. Except for some strata of the population, ORI has not really met its objective of attracting more pregnant women towards facility-based health care. Key words: maternal health, infant mortality, community-based health insurance, Mauritania, Sub-Saharan Africa VC The Author 2016. Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited. 1 2 Health Policy and Planning, 2016, Vol. 0, No. 0 Key Messages: • Indicators of maternal and neonatal health and access to care substantially improved in all health districts independently of the availability of the ORI. • Although there was no global effect of the availability of ORI on facility-based delivery rates, nor on the use of antenatal and postnatal care services, there was significant evidence of increasing access to birth deliveries in nearby health cen- tres at the expense of hospitals in the districts providing ORI. • Regardless of the availability of ORI, the education level of women strongly influences the use of maternal health services. • Neonatal mortality rates remained low and no global decrease was recorded with the availability of ORI. Introduction Blanchet et al. 2012; Frimpong et al. 2014; Ahiadeke 2015). Although >90% of pregnant women were covered in the two coun- Arose out of the United Nations Declaration of 2000, the tries, only 67% had facility-based deliveries in Rwanda and 57% in Downloaded from Millennium Development Goals (MDGs) have stimulated interest Ghana (Speizer et al. 2014; Twahirwa 2008; Lu et al. 2012; and encouraged funding for programs that aimed at reducing child Abrokwah et al. 2014). Finally, some results on increased antenatal mortality (MDG-4) and improving maternal health (MDG-5) care seeking and reduced out-of-pocket expenditure were inconclu- (Waage et al. 2010; Bryce et al. 2013). Among the different pro- sive given differing findings between studies (Brugiavini and Pace grams introduced, some health financial strategies have been initi- 2010; Chankova et al. 2008; Mensah et al. 2010; Singh et al. 2011; ated in Sub-Saharan Africa (SSA) to increase access to quality and http://heapol.oxfordjournals.org/ Smith and Sulzbach 2008). responsive maternal and perinatal health care, while providing fi- In Mauritania, Obstetric Risk Insurance (ORI) progressively im- nancial protection (De Allegri and Sauerborn 2007; Ridde et al. plemented at the health district level between 2002 and 2011 was 2011; Smith and Sulzbach 2008). Indeed, large amounts and unpre- based on pre-payment scheme principles and focused on increasing dictability of costs related to maternity remains one of the major quality and access to both maternal and perinatal health care. Our barriers for seeking health care (Ensor and Ronoh 2005; Kurfi et al. paper aims to assess the effectiveness of the ORI in increasing the 2013) as they absorb a significant amount of the financial capital in use of facility-based delivery care, as well as family planning, ante- the household, sometimes generating financial catastrophic expend- natal and postnatal care, caesarean delivery, and neonatal health. iture (Arsenault et al. 2013). We also examine whether the effects of ORI vary according to Among a variety of health financing systems, many pre-payment household wealth and women’s level of education to understand the at Universite de Montreal on October 24, 2016 scheme designs have been introduced at local and/or national level equity implications of the ORI approach. across SSA (Carrin et al. 2005; Ensor and Ronoh 2005; Smith and Sulzbach 2008). Basically, a pre-payment scheme aims at increasing health care utilization but also at providing financial risk Methods protection (Smith and Sulzbach 2008). The main difference with an insurance scheme lies in risk sharing, which is necessary in this case Public health system in Mauritania but not in the case of a pre-payment scheme. They are non-profit Located in Western Africa, Mauritania has a human development systems, based on voluntary affiliation, collective pooling of index ranking of 156 out of 186 countries in 2014 (source on UNDP resource and risk-sharing, and flat membership premiums (Carrin website). In 2013, the health expenditure represented 3.8% of the et al. 2005; Onwujekwe et al. 2009, 2010). The pre-payment GDP according to the World Bank, averaging in a health expend- scheme has been progressively incorporated into the national health iture per capita of 48.96 US$. The Maternal Mortality Ratio financing strategies of Benin, Ghana, Rwanda, Senegal and (MMR) in Mauritania was 602 per 100 000 live births in 2015 Tanzania with relative success (Smith and Sulzbach 2008; Borghi (based on World Bank data). In 2015, neonatal mortality was 36 et al. 2015). and under-five mortality of 85 (World Bank data). Following the implementation of pre-payment schemes in SSA, Mauritania’s public health system is organized in a common there has been evidence of increased utilization of pregnancy-related hierarchical pyramid: the central level, represented by the Ministry care, increased facility-based deliveries and improved financial pro- of Health; the intermediate level, made up of Regional Health tection due to reduced out-of-pocket expenditure in Guinea, Mali, Directorates («Directions Re´gionales de l’Action Sanitaire»: DRAS) Mauritania, Nigeria, Rwanda and Senegal (Adinma, Nwakoby and situated in the 13 Wilayas or regions; and the peripheral level, com- Adinma 2010; Chankova, Sulzbach and Diop 2008; Ndiaye et al. posed of 53 health districts re-grouping health centres and health 2008; Schneider and Diop 2001; Smith and Sulzbach 2008). In con- posts (Renaudin et al. 2007, 2008). In 2O13, there were 53 health trast, there are a few studies that failed to identify an effect of pre- districts distributed in 13 regions. payment schemes. For example, no significant difference in overall The public health care facilities are divided into three levels. At antenatal care services, facility-based deliveries and/or maternal the first level, health posts
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